Module 9

Pain

BSNC 2000
 OBJECTIVES

1. Define the concept of pain.

2. Compare and contrast acute, chronic,

nociceptive, and neuropathic pain.

3. Describe the normal physiological processes

involved in the transduction, transmission, and
perception of pain.
Concept of Pain
 DEFINITION

“An unpleasant sensory and emotional experience

with actual or potential tissue damage.”

Pain is whatever the experiencing person says it is,

existing whenever they say it does. (McCaffery,
1998)
Pain tolerance is physiologically identical between
individuals.
Pain threshold is the same, but pain tolerance will
differ.

What is the difference between threshold and

tolerance?
pain threshold
= level of painful stimulation required to be
perceived
– similar between individuals

pain tolerance
= the degree of pain that one is willing to bear
before initiating an overt pain response
– varies between individuals and within the
same individual under differing conditions
Classifications for Pain
 CLASSIFICATIONS

duration location etiology frequency

acute cutaneous nociceptive intermittent

somatic
chronic neuropathic constant
visceral
referred
 10 min
Breakout Room 6 groups

In your groups, match the pain descriptions to the

correct classification (next slide).
chronic visceral nociceptive

acute somatic neuropathic

acute referred neuropathic

chronic cutaneous nociceptive

acute neuropathic
visceral
 ACUTE vs CHRONIC

< 6 months > 6 months

constant or
DURATION
intermittent

tissue injury (trauma, cancer, arthritis,

surgery, infection, etc.) migraine, etc.
CAUSES
nociceptive pain nociceptive or
neuropathic pain

RESPONSES
FYI – chronic neuropathic vs. nociceptive pain
Why is acute pain important?
acute pain is a protective response
• alerts the person to actual or possible injury
• activates withdrawal reflex
• prompts medical attention
• leads to rest to allow the injury to heal
 ACUTE vs CHRONIC

< 6 months > 6 months

DURATION constant or intermittent

tissue injury (trauma, cancer, arthritis,

surgery, infection, etc.) migraine, neuropathy,
CAUSES
etc.

autonomic psychological /
behavioural
↑ HR, ↑ BP, dry mouth,
muscle tension, ↓ gut irritability, depression,
RESPONSES withdrawal from interests,
motility, sweating,
impaired relationships
anxiety, guarding
behaviours ↓ sleep, libido, appetite
Physiology of Pain
 NOCICEPTIVE PAIN

• the normal processing of a pain signal

(nervous system is functioning normally)

• caused by a noxious stimulus detected by

pain receptors
What is a noxious stimulus?
= a stimulus capable of causing tissue injury

intense pressure, swelling, stretch or

mechanical distension, incision, abrasion, tumour
growth

thermal burn, scald, frostbite

chemical mediators released from

chemical injured or inflamed tissues (bradykinin,
prostaglandins), acid
PHYSIOLOGY
OF PAIN
Includes:

1. transduction
2. transmission to
spinal cord and
brain
3. central perception
4. spinal modulation
① TRANSDUCTION

The process of converting

noxious stimuli to
neuronal action potentials
at the pain sensory
receptor (nociceptor).
 NOCICEPTORS

• ‘free’ nerve endings of sensory neurons that

detect noxious stimuli

• stimulation causes the opening of ion channels

and the generation of action potentials

• widespread, but uneven distribution

Where are nociceptors most abundant?
 skin
cutaneous many receptors

muscle, joints, tendons, ligaments,

somatic periosteum
many receptors (fewer than skin)

internal organs
visceral few receptors
②TRANSMISSION

The movement of the

action potential from
peripheral nociceptors
to the dorsal horn of
the spinal cord, and
then up ascending
tracts to the brain.
 SENSORY PATHWAYS

third order
Somatosensory
stimuli are detected
and transmitted to
the brain by a series
second order
of THREE sensory
neurons that form a
sensory pathway.
first order
Transmission of noxious stimuli to the spinal cord
occurs along either Ad fibres or C fibres (first-
order sensory neurons).

A𝛅 fibres
larger diameter,
lightly myelinated

C fibres
small diameter,
unmyelinated
 Ad fibre or C fibre?

• well localized, sharp, stinging,

pricking, “fast” or “first” pain

• diffuse, dull, burning, aching,

“slow” or “second” pain
 A𝛅 fibres
fast pain, sharp,
well-localized

C fibres
slow pain,
burning,
diffuse
DORSAL HORN
TRANSMISSION

Primary nociceptive fibres

(Aδ and C fibres) synapse
with 2nd order sensory
neurons in the dorsal
horn of the spinal cord.
 The 2nd order
neuron crosses
over to the
opposite side of
note - Ad-fibres also trigger the spinal cord to
a withdrawal reflex via ascend to the
connections to motor brain.
neurons in the spinal cord
Pain during a heart attack is felt in the left arm.
What type of pain is the arm pain?
Neurons carrying pain
stimuli from the heart
converge on the same 2nd
order neurons in the
spinal cord as sensory
neurons carrying stimuli
from the skin à pain is
felt in the arm (= referred
pain).
Local anesthetics (e.g. lidocaine) act by blocking
voltage-gated sodium channels. How do they
block pain?
Local anesthetics
block action
potential
generation and
conduction to
block transduction
& transmission.

FYI – note where the

various pain medications
target the pain pathway
 ASCENDING
PATHWAYS

Ascending nerve
tracts carry the pain
impulse to various
brain areas.
e.g. spinothalamic tract

• the main ascending

pain pathway
• 2nd order neurons
transmit the pain signal
to the thalamus (relay
station that determines
where to send the
information)
• 3rd order neurons
project to the cerebral
cortex
FYI – other ascending pain pathways

https://youtu.be/gcOqv0uzyAQ
③PERCEPTION

The brain receives the

brain signal. It identifies
and interprets it to
produce a response.

Perception involves
conscious awareness of
pain.
 What are the functions of the following brain areas
in the perception of pain?

somatosensory
cortex

limbic
system

hypothalamus
reticular formation
somatosensory cortex
identifies the presence, location, character, and
intensity of pain

hypothalamus
activates the stress response

limbic system
emotional response to pain & memory

reticular formation
increases alertness and awareness (of danger)
 recall… the prefrontal cortex is
involved in planning, reasoning,
judgement, problem-solving, etc.

What function does the prefrontal cortex play in

pain perception?
What factors might influence ones perception of
pain?
④MODULATION

Descending pathways
from the brainstem act
at the dorsal horn to
modulate the pain
signal.
Risk Factors for Pain
As a population group, older adults are at
greatest risk for pain. What factors contribute to
this risk?
Summary
 ③ PERCEPTION
= the brain receives the pain signal and interprets
it
• somatosensory cortex - identifies the type,
intensity, and location of pain
• reticular system - increases alertness and
awareness
• limbic system - responsible for the emotional
response to pain
• hypothalamus - responsible for autonomic
and endocrine responses (stress response)
ascending pathways
• secondary neurons cross-over the spinal cord
and ascend in nerve tracts to the brain
• the spinothalamic tract transmits the pain
signal to the thalamus where secondary
neurons synapse with tertiary (3rd order)
neurons that then ascend to the
somatosensory cortex
• ascending nerve tracts also project to the
reticular formation (brainstem), limbic system,
and hypothalamus
① TRANSDUCTION
= process of converting noxious stimuli to
neuronal action potentials at the pain sensory
receptor (nociceptor)
nociceptors
• pain sensory receptors that detect noxious
mechanical, chemical, or thermal stimuli
(capable of causing tissue injury)
• classified as somatic (skin, muscle, joints,
bone) or visceral (organs)
④ MODULATION
= synaptic transmission at the level of the dorsal
horn is altered by descending (supraspinal)
pathways
• inhibitory neurotransmitters to be discussed -
norepinephrine, serotonin, opioid peptides,
GABA
dorsal horn
• primary afferents synapse with secondary (2nd
order) neurons in the dorsal horn of the spinal
cord
• glutamate and substance P are important
neurotransmitters that act here to transmit
the message
primary (1st order) sensory neurons
Transmission to the spinal cord occurs along
either:
1. Aδ fibres - lightly myelinated axons; detect
mechanical and thermal noxious stimuli;
transmit impulses quickly (“fast” or “first”
pain); described as well localized, sharp, or
stinging pain; leads to the withdrawal
response
2. C fibres - unmyelinated axons; detect all
types of noxious stimuli; transmit impulses
more slowly ( “slow” or “second” pain);
described as diffuse, dull, burning, or aching
pain; leads to immobilization of the injured
part
② TRANSMISSION
= movement of the action potential from
peripheral nociceptors to the spinal cord, then
brain